Annals of surgery
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Comparative Study
Stab wounds of the anterior abdomen. Analysis of a management plan using local wound exploration and quantitative peritoneal lavage.
A management plan for stab wounds to the anterior abdomen incorporating local wound exploration and quantitative peritoneal lavage was applied to 572 patients. One hundred eighty-five of these patients presented with shock, peritonitis, or evisceration and underwent immediate exploratory laparotomy with the finding of an intraperitoneal organ injury in 183 (99%). The remaining 387 patients with a negative physical examination underwent exploration of the stab wound to determine fascial penetration. ⋯ No patients with lavage counts less than 1,000 red cells had an organ injury. Forty-three per cent of patients in the intermediate group (1,000-50,000 RBCs/mm3) had an organ injury and 59% included penetration of a hollow viscus. An approach incorporating local wound exploration and quantitative peritoneal lavage followed by exploratory laparotomy for red blood cell counts greater than 1,000 should result in less than 10% negative laparotomies and no missed injuries.
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Monitoring of ventricular function by central venous (CVP) and pulmonary wedge pressures (PCW) was compared with ejection fraction and end-diastolic volume (gated pool scan) in patients resuscitated from hypovolemic and septic shock. Sixteen patients were studied within 24 hours of resuscitation and all showed depressed right ventricular ejection (RVEF) and/or an increased end-diastolic volume (RVEDVI). Group I (eight patients, hypovolemia and sepsis) had low RVEF (mean, 0.30), high RVEDVI (mean 129.2 ml/m2), and nearly normal left ventricular function (LVEF 0.63 and LVEDVI 63.6 ml/m2), compared to angiographic normals (RVEF 0.52, RVEDVI 55.8 ml/m2; nL LVEF 0.59, LVEDVI 52.3 ml/m2). ⋯ Both LVEDVI and RVEDVI were correlated significantly with cardiac index and with each other. RV dysfunction occurs after resuscitation of hypovolemia and sepsis without reliable alteration in filling pressure and is likely related to myocardial ischemia as well as increased pulmonary vascular resistance. Survival seems to depend on improvement in RV performance, which can be measured at the bedside by cardiac scintigraphy.
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Between 1967 and July 1982, 1103 operations were performed for the tetralogy of Fallot of all types with 116 (10.5%) hospital deaths. Eighty-eight hospital deaths (10.5%) occurred in the 836 patients undergoing repair. The incremental risk factors for hospital death after repair include pulmonary arterial problems (p = 0.0002), major associated cardiac anomalies (p less than 0.0001), small size (young age) (p less than 0.0001), and more than one previous operation (p = 0.0004). ⋯ No iatrogenic pulmonary arterial problems have been recognized. Protocols based on these results are presented. Many of these selective recommendations may become unnecessary if the damaging effects of cardiopulmonary bypass are overcome by future research.
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Since adopting a policy of immediate operation on patients with acute dissection of the ascending aorta, 42 men and 6 women (ages 18-67 years) have been managed surgically. Thirty-two patients had graft replacement of the ascending aorta and resuspension of the incompetent aortic valve. One of these had a coronary graft. ⋯ On the basis of this experience, prompt surgical intervention for acute ascending aortic dissection is the treatment of choice. A variety of techniques are available to repair the dissected aorta. Long-term results for resuspension of the aortic valve in acute ascending aortic dissection have been excellent and emphasize that valve replacement should be reserved for those patients found at operation to have a primary abnormality of the aortic valve.
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Randomized Controlled Trial Clinical Trial
Randomized trial of efficacy of crystalloid and colloid resuscitation on hemodynamic response and lung water following thermal injury.
To assess the effects of crystalloid and colloid resuscitation on hemodynamic response and on lung water following thermal injury, 79 patients were assigned randomly to receive lactated Ringer's solution or 2.5% albumin-lactated Ringer's solution. Crystalloid-treated patients required more fluid for successful resuscitation than did those receiving colloid solutions (3.81 vs. 2.98 ml/kg body weight/% body surface burn, p less than 0.01). In study phase 1 (29 patients), cardiac index and myocardial contractility (ejection fraction and mean rate of internal fiber shortening, Vcf) were determined by echocardiography during the first 48 hours postburn. ⋯ Cardiac index increased progressively and identically in both treatment groups over the study period (p less than 0.01). These data refute the existence of myocardial depression during postburn resuscitation and document hypercontractile left ventricular performance. The addition of colloid to crystalloid resuscitation fluids produces no long lasting benefit on total body blood flow, and promotes accumulation of lung water when edema fluid is being reabsorbed from the burn wound.